Thursday, July 30, 2009

This past weekend was the annual urban miracle in Buffalo, home to the nation's largest open urban Garden Walk.

The creativity is staggering -- and it's as much about found objects and easy integration of dramatic urban backdrops as about the profusions of perennials that Buffalo gardeners favor. Somehow these intense, concentrated urban Ozzes make bigger suburban gardens seem pallid.

Pics from 2008 Walk are here; from 2007, here. And in case you missed it above, 09 is here.

Wednesday, July 29, 2009

In a long interview with Obama on healthcare, Time's Karen Tumulty pressed the President on an example of a tough cost/benefit decision on treatment he had raised in an April interview with David Leonhardt -- a hip replacement Obama's grandmother received at the very end of life, when she was terminally ill with cancer. Should Kaiser Permanente have paid for the operation? They did - and Tumulty asked whether that was a good use of healthcare dollars. Obama's answer was evasive - and properly so, I think:

I guess my point is, is that you don't even get to those really tough decisions, you don't even have to get to those really tough decisions before you've already saved a huge amount of money and made people healthier and made sure that Medicare was solvent and bent the cost curve. I mean, there's 20, 25% of the cost — of the system that is wasteful right now, even before you get to tough decisions about end-of-life care...

Let's just take one example, and that is testing. It turns out that we pay 10 times what Japan pays, for example, for CAT scans and MRIs. Well, why is that? And it turns out, by the way, that we are having those tests five, six, eight times as often as folks in other countries who have just as good outcomes.

Now, some of that may have to do with reimbursement models. There may be differences that have to do with the approach that hospitals here take in recovering costs for expensive equipment. There are a whole range of reasons why that might be true, but the point is, is that it's not like people out there are — would automatically be prevented from getting CAT scans if we just tried to think when is a CAT scan or an MRI working and appropriate in improving care and when it's not.

And what we've said is that if doctors and patients had that information, and you start changing some of these delivery systems, you will see significant changes in the cost of health care and you will see improved outcomes and improved convenience, because if people are going through a battery of tests when one test would be sufficient, every time they're going to the doctor, that's gas, babysitting, sitting around for two hours, a day off work. We're not even factoring in those costs.

Obama is right that the U.S. should be able to save huge amounts by eliminating patently unnecessary care, regardless of how public and private insurers resolve the really tough cost/benefit decisions. What he did not make clear in this interview, however -- and I wish Tumulty had pushed him on this as she did on his grandmother's operation -- was how currently proposed legislation would signifcantly change those skewed incentives he keeps citing. He gave a kind of answer to Fred Hiatt on this question -- "MedPAC on steroids." But we need to hear way more about this.

According to the Heritage Foundation's Robert A. Book, it's a myth that Medicare controls costs better than private insurers. The slower growth in Medicare spending is due mainly Medicare shifting more costs onto patients and their other insurance sources:

Medicare's share of total spending on health care services for non-institutionalized Medicare enrollees fell from 72.2 percent in 1997 to 50.8 percent in 2005.[27] The remaining 49.2 percent was covered by a combination of private insurance, including employer-sponsored insurance (for employees and retirees) and individually purchased Medigap plans (21.4 percent); beneficiaries' out-of-pocket spending (15.7 percent); and other public plans, including TRICARE, Veterans Health Administration, and Medicaid (12.0 percent). Total spending per capita in 2005 was $12,157, including $6,180 paid by Medicare and $2,603 paid by private insurance.[28]

Over time, Medicare's share of health care spending for Medicare beneficiaries has fallen, while private insurance's share has risen. In 1997, Medicare's share was 72.2 percent, and the private-insurance share was 12.2 percent. Total spending per capita in 1997 was $5,438, including $3,925 from Medicare and $662 from private insurance.[29]

While total per-capita health care spending for Medicare enrollees increased by 124 percent from 1997 to 2005 (an average of 10.6 percent per year), spending by the Medicare program increased by only 57.5 percent (5.8 percent per year). Meanwhile, private insurance spending on Medicare beneficiaries increased by 294 percent (18.7 percent per year), and out-of-pocket spending by Medicare beneficiaries increased by 205 percent (15.0 percent per year).

Book also claims that Medicare does not have lower administrative costs than private plans, that it does not use superior bargaining power to reduce costs, and that it is not more innovative than the private sector.

Book takes on Jacob Hacker and Paul Krugman, amongst others. I'd be interested to see a detailed rebuttal.

It's widely assumed that this would be an effective tool for reducing healthcare inflation, since businesses would have an incentive to keep their healthcare spending per employee below the cap. It's also generally assumed that Obama is resisting this measure because it was a central plank in McCain's healthcare "plan" (such as it was), which Obama campaigned against.

But Obama's answer to Hiatt's question is interesting, and compelling:

Now, this is something that I think economists find appealing partly because it's -- although it's a blunter instrument, it's more measurable than some of the delivery system changes -- although I actually think the delivery system changes are more long-lasting. And you could have a situation in which you cap the exclusion or eliminated the exclusion and, yes, that would drive health care inflation down, but it also could drive quality of health care down because you're not doing anything to change a perverse system in which we pay for more medical care as opposed to medical care that actually makes us healthier.

In other words, as long as a healthcare plan is still indiscriminately reimbursing doctors and hospitals on a fee-for-service basis, the only way it can cut costs is to cut coverage -- and Americans' health plans are already riddled with holes, rising copays, uncovered treatments, lifetime benefit caps. Obama is saying that he does not want to mandate private sector benefit cuts until those cuts will be directed at unnecessary care -- MRIs for every muscle strain, Caesarians for every slow birth, unnecessary prostate cancer operations, proton radiation, the whole panoply of wasteful testing, operating, medicating that Americans have been trained to expect -- rather than against necessary preventive and catastrophic care, which so many plans today cover inadequately.

Obama did tell Hiatt that he'd be open to a cap on the healthcare tax exemption set above today's top spending levels. Obama's thinking/political framing of this issue is structurally similar to his approach to corporate taxation: he is open in principle to reducing the corporate tax rate if and when Congress closes the huge array of loopholes that make the effective corporate tax rate so much lower than the nominal rate. In both instances he is seeking to avoid change with unintended consequences -- or perhaps with stealthily intended consequences -- by insisting that structural change precede a reform that will misfire without it.

In the Hiatt interview, after pivoting away from the tax exemption cap, Obama placed his cost curve-bending chips on "MedPac on steroids," a commission empowered to set reimbursement rates and treatment emphases for Medicare and Medicaid. He cast MedPac as perhaps the chief vehicle for tackling the real fundamental task-- moving the healthcare payment system away from fee-for-service and towards some kind of global payment system, where doctors and hospitals are paid per patient, with performance incentives.

At this point, I am confident that both the House and the Senate bills will contain what we've been calling MedPAC on steroids, the idea that you continually present new ideas to change incentives, change the delivery system, understanding that because this is such a complex system we're not always going to get it exactly right the first time, and that there have to be a series of modifications over the course of a series of years, and we have to take that out of politics and make sure that an independent board of medical experts and health economists are providing packages that are continually improving the system. So I think there's general consensus that that is one of two very powerful levers to bend the cost curve.

The role that Obama envisions for MedPAC is a window on the way he conceives of systemic change generally. He's what you might call a radical incrementalist. Recognizing that the fundamental task in tackling healthcare inflation is to change incentives -- end fee-for-service -- he also recognizes that the payment system cannot be changed by fiat, that the task needs to be done in stages, experimentally, on the basis of what is shown to work. To empower MedPAC in Obama's view is to create a "powerful lever" to "move this big battleship a few degrees in a different direction" and set the stage for a long series of subsequent reforms.

Saturday, July 25, 2009

Fee-for-service, fee-for-service, fee-for-service. Gradually the healthcare debate is centering on this major driver of runaway healthcare inflation. Atul Gawande and David Leonhardt have helped shine the spotlight on doctors' incentives to provide unnecessary care; Peter Orzag and Barack Obama (see "p.s." at link) have seized on their examples and language.

Today, the New York Times is front-paging a new poster child for putting doctors on salary. Gardener Harris profiles Bassett Healthcare, "a modest hospital of 180 beds" in Cooperstown, NY, to demonstrate that you don't have to be the Mayo Clinic to improve outcomes by realigning incentives, a.k.a. putting doctors on salary:

Bassett — like the Cleveland Clinic and a small number of other health systems in this country — pays salaries to all of its doctors. No matter how many tests or procedures are performed, they take home the same amount of money. Medical costs at Bassett are lower than those at 90 percent of the hospitals in New York, while the quality of care ranks among the top 10 percent in the nation, surveys show.

As at the Mayo Clinic and other treatment centers that have eschewed fee-for-service, the payment structure goes hand-in-hand with coordinated, integrated patient care:

Michelle Griffiths, 41, of Edmeston found a lump on her breast six years ago. During cancer care at Bassett, Ms. Griffiths’s appointments to see her oncologist and primary care doctor are often scheduled on the same day. One doctor will sometimes accompany her during a procedure performed by another, and each has her complete medical history.

“The communication amongst all of my doctors is impressive,” said Ms. Griffiths, who works as a database administrator for the insurance company New York Central Mutual. “They always call each other or shoot each other e-mails.”

Such coordinated care is a hallmark of integrated health systems with salaried doctors, like Kaiser Permanente, the Mayo Clinic, the Veterans Administration and the Cleveland Clinic.

Harris also highlights the political conundrum: everyone seriously engaged in healthcare reform knows that fee-for-service is a major inflation culprit. But as in the Aesop's fable in which a group of mice agree that they should hang a bell around the cat that's been gobbling them up, no one knows how to "bell the cat":

“Everyone knows that the Bassett model is the right model,” said Senator Charles E. Schumer, a New York Democrat involved in negotiations over health care legislation. “The question is, How do you get from here to there?"

In response, I wonder why the unanamious recommendations of the Massachusetts Special Commission on the Health Care Payment System are not getting more attetention. The Commission's central proposal takes direct aim at fee-for-service, proposing a five-year transition to "global payment systems" that pay doctors and hospitals per patient, with performance incentives, and adjustments for region, income, clinical risk and other factors. The recommendations appear to have broad, if cautious and equivocal support. The Times' Kevin Sack reports:

Top state legislators said that they recognized the political challenge in enacting such a plan but that Massachusetts’ circumstances demanded it. Senator Richard T. Moore, co-chairman of a joint legislative committee on health care financing, said he expected to hold hearings on the recommendations this fall. The committee’s other leader, Representative Harriett L. Stanley, said, “It’s going to be a very long haul, but it’s a trip worth taking.” [snip]

Interest groups with heavy stakes embraced the proposal, but warily.

“Hospitals want to be part of this historic endeavor,” said Lynn B. Nicholas, president of the Massachusetts Hospital Association. But Ms. Nicholas added that “the success of moving to a global payment system is not a foregone conclusion” and expressed concerns about how risks would be adjusted and how start-up costs would be covered.

The president of the state medical society, Dr. Mario E. Motta, also urged caution. “A big transition like this has never been done on such a broad scale,” Dr. Motta said, “so it must be done very carefully, deliberately andthoughtfully.”

In Massachusetts, turning the battleship toward global payment systems appears to be recognized as a necessity if the 2006 reform plan that's already achieved near-universal coverage is not to bankrupt the state, as it's beginning to do. (Of course, the state has only taken a baby step toward reforming the payment system.) Will federal legislation have to follow the same road - extend coverage first, deal with the resulting financial emergency as it takes hold?

Friday, July 24, 2009

Two Kenyan students are hoping to market a device that allows bicycle riders to charge their mobile phones.

Jeremiah Murimi, 24, and Pascal Katana, 22, said they wanted their dynamo-powered "smart charger" to help people without electricity in rural areas.

"We both come from villages and we know the problems," Mr Murimi told the BBC.

People have to travel great distances to shops where they are charged $2 a time to power their phone, usually from a car battery or solar panel....

Mr Katana explained it takes an hour of pedalling to fully charge a phone, about the same time it would if it were plugged into the mains electricity....

The cash-strapped students used old bits of electronic equipment for the project.

"We took most of [the] items from a junk yard - using bits from spoilt radios and spoilt televisions," said Mr Katana.

This has been done before in other countries - who knew? There is something incredibly suggestive about powering a phone by pedaling a bike. It seems somehow to capture the mystery of mind arising out of body.

Wednesday, July 22, 2009

In his health care press conference tonight, Obama stressed repeatedly that most "sacrifice" required from health care cost reduction should come from "sacrificing" unnecessary and ineffective treatments -- which makes sense when you consider that Americans spend in the neighborhood of 70% more per capita on health care than citizens of other wealthy countries without gaining any better outcomes. He went so far as to spell out that doctors in the U.S. too often have financial incentives to prescribe unnecessary treatment.

Personal experience leads me to quibble, though, with one of his examples of wasteful care, which made cost-benefit decisions seem cost-free. He said, “If there’s a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that’s going to make you well?”

As it turns out, my own highly competent and socially responsible primary care physician some time ago prescribed generic Simvastatin to bring down my cholesterol. It didn't work well, though later conversation revealed that occasional 1-2 week gaps that I let slip between prescription refills may have been responsible. When a checkup revealed that my cholesterol levels had not improved, I asked her if I wouldn't do better with Lipitor. She said that Lipitor, which is not available generically, would cost me much more (and she might have added, cost the insurer much more), and "only" deliver perhaps a 5-10% advantage. (While writing this, I checked that estimate out, and found a Pfizer report touting a study result purporting to show a 14% advantage for Lipitor over competitors, including Simvastatin. This was a "report" that read awfully like a Pfizer press release on a site of dubious provenance, with no "about" section.)

Assuming that my doctor was roughly right about the 5-10% Lipitor advantage , this was exactly the situation that Obama sketched -- except that there was a genuine cost-benefit choice to be made. Would a modest improvement in drug performance be worth an additional $20/month to me - and God knows how much to the insurer? That's a very complex calculation; variables include my age, the extent to which my cholesterol numbers were worrisome, and my overall cardiovascular profile (e.g., a C-reactive protein test that yielded a good result); whether my insurer should have paid for that test is a whole other question). I am currently trying again with Simvastatin.

Were I on Medicare, would an empowered MedPac oversight panel making decisions about what treatments to fund approve prescribing Lipitor to me? Would the doctor have any incentive to say, 'first try taking your Simvastatin regularly'? And it would be nice if someone wouldmandate that my insurer allow me to buy a three-month's supply at a time, so I'd be likelier to refill on time.

Obama himself has pointed out in other contexts that bringing medical costs under control will ultimately entail more agonizing choices. Here is an April 28 exchange with David Leonhardt, foreshadowing the MedPac proposal:

Now, I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care —

LEONHARDT: Yes, where it’s $20,000 for an extra week of life.

THE PRESIDENT: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.

So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.

I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.

And it’s going to be hard for people who don’t have the option of paying for it.

THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?

I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

So how do you — how do we deal with it?

THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

Difficult choices notwithstanding, American health care practice is rife with overprescription of scores of tests, operations, drugs and other treatments of dubious value, or of value only a fraction of the times they are prescribed. Don't get my wife, a nurse midwife, started about amniocentesis, a procedure usually about as valuable as a trip to the Oracle at Delphi. Not to mention Caesarian sections, which at her hospital are performed on something approaching 40% of births.

P.S. Leonhardt must have crowed tonight to hear the President adopt the lede from Leonhardt's 7/22 front page article, which framed the President's communication challenge as explaining to the American people re health care reform, what's in it for me? In his prepared remarks, Obama used the very words:

I realize that with all the charges and criticisms being thrown around in Washington, many Americans may be wondering, "What's in this for me? How does my family stand to benefit from health insurance reform?"

The distance between the status quo anda perfect bill is so vast that we could have something that's both a massive, historical improvement and a crushing disappointment. That's what I think we'll get.

Aw, come on, Jon. How about a bill that's a moderate disappointment with flaws that can be chipped away in followup legislation? E.G., cost-control measures with real teeth, like global payment systems. It's possible that partial success in the initial bill -- say, expanded coverage with weak cost control -- will create both the momentum and the imperative for subsequent fixes. As may be happening in Massachusetts.

The New York Times' David Leonhardt seems to have taken it upon himself to drive home to Americans that the nub of healthcare cost containment is removing doctors' and hospitals' incentives to prescribe unnecessary care. From today's front page article:

On Thursday, Mr. Obama will visit another example he likes to cite, the Cleveland Clinic. Its successes capture what real reform would look like. Like Mayo, the Cleveland Clinic pays its doctors a salary, rather than piecemeal, and delivers excellent results for relatively little money.

“I came here 30-some years ago,” Delos Cosgrove, a heart surgeon who is the clinic’s chief executive, told me. “And I have never received any additional pay for anything I did. It never made a difference if I did five heart operations or four — I got paid the same amount of money. So I had no incentive to do any extra tests or anything.”

This is the crux of the issue, economists say: the current fee-for-service system needs to be remade.

In shining the spotlight on pay structures, Leonhardt seems to be trying to do the work he thinks Obama should be doing. He frames Obama's core task as teaching Americans that we're all overpaying in hiddden ways for healthcare to the tune of $6,500 per year per family, if you compare U.S. healthcare costs to those of typical wealthy countries. He complains that Obama has so far failed to invest his political capital, either to educate Americans or to fight for cost containment provisions with teeth:

Mr. Obama says many of the right things. Yet the White House has not yet shown that it’s willing to fight the necessary fights. Remember: the $6,500 tax benefits someone. And that someone has a lobbyist. The lobbyist even has an argument about how he is acting in your interest.

These lobbyists, who include big names like Dick Armey and Richard Gephardt, have succeeded in persuading Congress to write bills with a rather clever feature. They include some of the ideas that would cut costs — but defang them.

Interestingly, Leonhardt then dismisses one element of proposed House leglislation that would address the incentives problem as thus "defanged":

One proposal would pay doctors based on the quality of care, rather than quantity, but it’s a pilot project. Doctors who already provide good care may well opt in; doctors providing wasteful but lucrative care surely will not.

Perhaps. But to change the incentive structure for doctors, hospitals and other caregivers is to move an enormous battleship. The radical, unanimous proposal of a blue-ribbon helathcare commission in Massachusetts to replace fee-for-service with global payment systems proposes a five-year phase-in, noting the complexities: ""global payment rates will include adjustments for clinical risk, socio-economic status, geography (if appropriate), core access and quality incentive measures, and other factors." Perhaps a pilot program is not a bad place to start on the Federal level, in concert with other cost containment measures like a Medicare oversight commission to set rates and determine reimbursable procedures.

Monday, July 20, 2009

While Buffalo celebrates its profusion of green thumbs in its amazing annual Garden Walk on July 25, the world will be breaking out in a different kind of green. Cities across the globe will stage demonstrations in support of Iran's Green movement -- the brave Iranians still challenging the apparently rigged election that returned the dangerous demagogue Mahmoud Ahmadinejad to power.

As a Buffalo expatriate planning my annual Garden Walk pilgrimage, I was disappointed when I realized I would miss the opportunity to participate in the United4Iran demonstration in New York City this Saturday. Then I thought, why not invite the great gardeners of Buffalo to go "double green"?

Green ribbons, green scarves, green cloth of any kind is now recognized worldwide as a gesture of solidarity with Iran's "Green" supporters of reformist candidate Mir-Houssain Mousavi, who has not conceded the stolen election. Signs reading "Where is My Vote?" are a more direct way to express support. Perhaps the Garden Walk sidewalk signs could leaf out in this manner.

Sunday, July 19, 2009

I wanted to post notice of a key development on the healthcare cost containment front reported in the WSJ on Friday, but didn't get around to it (settling for a tweet) -- and now I see that Ezra Klein has beaten me to it. Here's the WSJ:

A Massachusetts panel proposed that the state scrap traditional payments to doctors and hospitals for each office visit or procedure, and instead adopt a system where they receive a monthly or annual fee per patient.

The proposal is an effort to control the state's health-care costs, which are among the highest in the nation.

Under the new system, doctors and hospitals would be organized into groups responsible for all of a patient's health-care needs. The groups would receive a "global payment" per patient, which could be adjusted with performance incentives based on the quality of care provided.

The proposed system -- a radical departure from the way patients and insurers now pay -- would require legislative action and waivers from Medicaid and Medicare rules.

The panel, created by state law, voted unanimously to adopt the recommendations. The commission included key state legislators, the state's leading doctor and hospital associations and insurers.

As Klein says:

That's a huge reform. Much bigger than anything we're considering nationally. It's a direct attempt to change the behavior of politically powerful providers to preserve the coverage that the reforms gave to individuals. It will be difficult. The doctors' lobby is already giving angry quotes to the press.

Atul Gawande, in his landmark article focusing the healthcare debate on the problem of health care providers' incentives (mainly payment per treatment), stressed the complexities of realigning those incentives:

Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.

This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.

Dramatic improvements and savings will take at least a decade.

Massachusetts' Special Commission on the Healthcare Payment System (full report here) is proposing to cut the Gordian knot - to end payment per treatment in one fell swoop. In fact, though, there is nothing simple about the proposal, other than recommending unequivocally that the core transition to "global payment" be mandated. The Commission proposes a phase-in period of five years., and makes it clear that developing the global payment system will be a complex undertaking -- "global payment rates will include adjustments for clinical risk, socio-economic status, geography (if appropriate), core access and quality incentive measures, and other factors." The Commission recommends all the reforms outlined by Gawande and then some - development of "accountable care organizations," development of uniform standards of outcome assessment, implementing pay for performance incentives, building consumer incentives for preventive care.

The lobbying machinery is cranking up to crush the panel's initiative. Can Massachusetts legislators, under cover of a unanimous blue-ribbon commission, withstand the pressure? Can Massachusetts, which led the way in extending near-universal coverage, now lead the way in containing costs? Or will this fundamental reform fade away. to be replaced by nibblings around the edges of health care cost control?

Saturday, July 18, 2009

From Green Brief 31, perhaps the best current source for news inside Iran, a couple of snippets highlighting the tenor of state-sanctioned worship in the Islamic Republic:

Karroubi was assaulted in front of Tehran University as he tried to enter the compound to join the prayers.

It is worth mentioning that there was a loudspeaker inside the mosque which chanted, "Death to America!", but every time that slogan was heard, people loudly replied with, "Death to Russia, Death to China!"

Many women were reportedly stabbed with knives by Basijis dressed as women. Several mosques around the city were packed with Basijis waiting to come out and clash with protesters...Basijis even attacked people who had come to prayers.

The Basij are religiously indoctrinated from an early age as they're trained in the means of state terror. This is the modus vivendi of the theocracy established by Ayatollah Khomeini, the "enlightened Imam," according to Mousavi, who brought "unprecedented enlightenment" to Iranian society -- and who, according to Rafsanjani yesterday, "always said that without the participation of the people the Islamic government would never be successful."

Let's recall that compared to Khomeini, the Khamenei-Ahmadinejad thugocracy is kind and gentle. Instead of mass beatings, the enlightened Imam went in for mass executions, untold tortures, and, when war came, human wave sacrifices of indoctrinated teens. He also empowered a cadre of theocrats, starting with himself, to place their own authority ahead of that of the Koran -- let alone the people.

Can those who devoted their life's service, and continue to pay lip service -- and probably heart service -- to one of the twentieth centuries last great killers lead a movement for meaningful change? Perhaps, for a season. Gorbachev did it.

Friday, July 17, 2009

Muhammad Sahimi at Tehran Bureau believes that Rafsanjani's sermon at Friday prayers earlier today "is bound to reinvigorate the democratic movement" because Rafsanjani implicitly validated the people's doubt in the election results and "demonstrated the glaring fissures in the leadership of the Islamic Republic."

True enough. But to an outsider reading a rushed transcript, it also seems that Rafsanjani effectively gave up on challenging the election results. Rather, he seemed to call for effectively palliating the wronged electorate by granting fredom of assembly and freedom of speech without offerng the possiblity that those acts would yield any concrete change. That is, he called for freeing the prisoners, consoling the mourners, and freeing the media instead of addressing their grievances with action. Below, I've highlighted what seems to me the key pivot in the political part of the speech.

The most important thing that has happened is that the trust that brought the people to vote in such large number is not there anymore.We need to return this trust.We all need to follow the law. And I’m talking about the government, the parliament, the Islamic Courts and the security forces.We need to follow the laws.All problems can be solved if we only follow the framework of the laws.We need to create an environment where all sides could come together and discuss their issues.We need to be able to sit down like brothers and sisters and talk about our differences.Unfortunately, The chance that was given to the Guardian Council of five days to get people together and regain their trust was not used. That is not there anymore. But we still have time to unite.

We shouldn’t imprison our own people,We should let these people return to their homes,We shouldn’t let our enemies laugh at us because we’ve imprisoned our own people.We should sit together with mourners,And we should console them,And bring them back closer to the system.We should not be impatient now.

Please do not censor media outlets that have legally obtained permits.Let them do what they want to do legally.Allow a peaceful and friendly environment to prosper.We are all together in the Islamic Revolution,We’ve all spent years in suffering,We’ve all given martyrs for the cause of the revolution,This unity needs to fostered.

I’m hopeful that we will be able to achieve this unity in the future,And I’m hopeful we will get out of this situation,Based on the wishes of the people,And consensus among the leaders.

Rafsnajani, like Mousavi, claims that theocracy and republicanism, are the twin pillars of the Islamic Republic:

this is a theocracy,A theocratic republic.(People chanting)Be patient, be calm.If the government is not Islamic, then we are heading no where.If it is not a republic, then it doesn’t amount to anything..

Effectively, though, a theocratic republic seems to give the people democracy when they agree with the theocrats. Rafsnajani calls at the end for unity, for consensus among the leaders. But the "chance" squandered by the Guardian Council, charged with investigating the announced election results that they subsequently rubber-tamped, "is not there any more." So where does that leave Iranians? Rafsanjani has no answer.

Karim Sadjadpour of the Carnegie Endowment for International Peace has distinguished himself as one of the best-informed analysts of the post-election situation in Iran. His 7/16 q-and-a includes several crucial points about the coterie now in control, the opposition's prospects, the likely course of nuclear negotiations and the regime's vulnerabilities.

In sync with those who have detailed the militarist takeover that has progressed over the course of Ahmadinejad's four years in power, Sadjadpour stresses that not only the Iranian masses but large swaths of the country's elite, are now beating their wings against the tightly spun web of the current ruling coterie:

First of all, the idea of the Islamic Republic of Iran is now over. It has lost any claims of being a ‘republic.’ Past Iranian governments didn’t necessarily represent a wide swath of Iranian society, but they certainly encompassed a fairly wide swath of the Iranian political elite. Now the country is being run by a small cartel, which I would argue, reflects not only a very narrow swath of Iranian society, but also a narrow swath of Iran’s political elite. It’s a cartel of hardline clerics and Revolutionary Guardsmen who have benefitted tremendously from the oil bonanza of the last few years. They made nearly $300 billion in oil revenue the last four years and don’t want to share power. They are self-proclaimed ‘principlists’ but in reality their only real principles are power and money.

This duality runs throughout Sadjadpour's exposition: the regime lacks legitimacy, and the means to sustain the economy and social peace -- but as of now it has the guns. Some key points on both sides of this equation:

On who's really in control (after acknowledging opposition to regime among top-level clergy):

What we’ve seen in Iran over the last decade, however, is that the institution of the Revolutionary Guards has eclipsed the institution of the clergy, in terms of their political and economic clout. So while the cleavages amongst clerical elite is certainly significant, what would be a far more fatal blow to Ahmadinejad and Khamenei would be open dissent amongst the Revolutionary Guard elite, which we haven’t yet seen.

On the prospects for "cracking" the Revolutionary Guard:

The senior commanders of the Revolutionary Guards were handpicked by Khamenei, they owe their positions to Khamenei, and at the moment at least I think they’re unlikely to challenge him. But there’s a lot of anecdotal and some empirical evidence to show that the rank and file of the Revolutionary Guards is more reflective of Iranian society at large. They are not simply 120,000 radicals who are ready to martyr themselves to retain Ahmadinejad’s presidency, as one of the senior commanders recently alluded.

On negotiating with the current regime:

...I understand the Obama administration has decided that the nuclear clock is too urgent an issue to delay negotiations. But we should be clear about something: The problem we have with Iran has far more to do with the character of the regime than their nuclear program. The reality is that as long as Khamenei, Ahmadinejad and company are in power, we’re never going to reach a nuclear accord which sufficiently allays our suspicions—and Israel’s suspicions—that Iran is pursuing a weapons program. Any such accord would not only require Tehran to significantly curtail enrichment and agree to an intrusive inspections regime, it will also require them to modify their hostility toward Israel and alter their relationship with groups like Hezbollah. The chances of this happening as long as Ahmadinejad is president and Khamenei is Supreme Leader are very slim

On oil as arbiter:

But the country that has the greatest potential to influence internal Iranian affairs in the short term is Saudi Arabia. The Iranian economy is heavily reliant on oil revenue, and each one dollar drop in oil prices is nearly one billion dollars of lost annual revenue for Iran. If Saudi Arabia—whose relations with Iran have deteriorated since Ahmadinejad became president—were to quietly increase output in order to provoke a price drop it could prove devastating to Iran, far more damaging than any sanctions that are now being deliberated.

That last point is pretty arresting. It lead me to dream of political impossibilities: suppose the Obama Administration and Congress could get its act together and impose a hefty tax on oil whenever it hit a given price floor - say, $60/barrel? That would cut consumption and keep the price of oil down, which also "would be more damaging than any sanctions that are now being deliberated."

Thursday, July 16, 2009

Jeffrey Goldberg, asked by Michael J. Totten what he learned from talking to Hamas, responds:

A first-hand understanding of how they think. People in the United States find it hard to understand how people in Hamas and Hezbollah think. It’s alien. It’s alien to us. The feverish racism and conspiracy mongering, the obscurantism, the apocalyptic thinking – we can’t relate to that. Every so often, there’s an eruption of that in a place like Waco, Texas, but we’re not talking about 90 people in a compound. We’re talking about whole societies that are captive to this kind of absurdity.

Hmm. Are conspiratorial thinking, obscurantism and apocalyptic thinking "alien" to the 100 million-plus evangelicals living in the United States -- and controlling much of the Republican Party's agenda and rhetoric?

Reza Aslan, in his new book How to Win a Cosmic War, notes that Evangelical leaders, like International Jihadists, view life on earth as a grand apocalyptic struggle -- and often as an apocalyptic struggle between Christianity and Islam (when they're not busy casting it as a war between Christianity and Godless western hedonism). Aslan's equivalences are rather loose and broad. He's right, though, that fundamentalisms in all of the Biblical religions share some core assumptions about spiritual warfare -- internal, cultural, global and cosmic. Some samplings of U.S. Evangelical leaders' "church militancy," from Aslan and others:

"The Christian home is to be in a constant state of war"-- Ted Haggard, who before he lost his own "war" against his homosexuality, was head of the National Association of Evangelicals, representing 30 million conservative Christians. As such, Haggard was a high profile participant in weekly conference calls between evangelical leaders and the Bush White House (Aslan, p. 86).

Haggard on Islam: "The Christian God encourages freedom, love, forgiveness, prosperity and health. The Muslim god appears to value the opposite. The personalities of each god are evident in the cultures, civilizations and dispositions of the peoples that serve them."

Jerry Falwell on Islam:: "I think Muhammad was a terrorist. I read enough by both Muslims and non-Muslims, [to decide] that he was a violent man, a man of war."

Falwell on why 9/11 occurred: "throwing God out successfully with the help of the federal court system, throwing God out of the public square, out of the schools. The abortionists have got to bear some burden for this because God will not be mocked. And when we destroy 40 million little innocent babies, we make God mad. I really believe that the pagans, and the abortionists, and the feminists, and the gays and the lesbians who are actively trying to make that an alternative lifestyle, the ACLU, People for the American Way — all of them who have tried to secularize America — I point the finger in their face and say 'you helped this happen.'"

Falwell on culture war: "The local church is an organized army equipped for battle, ready to charge the enemy. The Sunday school is the attacking squad...[the missionary's task is to] bombard our territory, to move near the coast and shell the enemy" (Aslan, p. 86).

John Hagee, he of the coveted McCain endorsement, speaking on NPR of the Islamic threat: "those who live by the Qur'an have a scriptural mandate to kill Christians and Jews... it teaches that very clearly...There are 1.3 billion people who follow the Islamic faith, so if you're saying there's only 15 percent that want to come to America or invade Israel to crush it, you're only talking about 200 million people. That's far more than Hitler and Japan and Italy and all of the Axis powers in World War II had under arms."

More broadly, Aslan sees in the broader Evangelical community the kind of paranoia and magical thinking that Goldberg assumes is "alien" to Americans -- and in the process, notes the extent of its political influence:

There exists in this movement a socially constructed atmosphere of crisis, conflict, and threat derived from the perception that, as those who have been 'born again,' evangelicals have inherited God's covenant from Israel. They are the new chosen people, and like the Israelites of old, they must forever be tested by God and despised by the world.

This self-imposed worldview of constant embattlement can be impervious to reality. In the United States, where there are more than one hundred million evangelicals ...where in 2004 almost half of the Senate and a third of the members of the House of representatives were given an approval rating of 80 to 100 percent be evangelical watch groups, and where, until recently, the president and a great many members of his cabinet and staff were practicing evangelicals, a constant lament of evangelical leaders such as Tony Perkins of the Family Research Council and Richard Land of the Southern Baptist Convention is that the rights of evangelicals are being trampled upon because, for instance, they are not allowed to have prayer in public schools or post the Ten Commandments on government property. As the Sociologist Christian Smith has noted, the Evangelical movement's vibrancy, its ability to sustain a distinctive religious subculture, is owed precisely to this constructed sense of siege. Without it, Smith writes, the movement would 'lose its identity and purpose and grow languid and aimless' (p. 91).

Compare Thomas Frank on that avatar of the Christian right, Sarah Palin:

The piling-up of petty complaints is an important aspect of conservative movement culture. For those who believe that American life consists of the trampling of Middle America by the "elites" -- that our culture is one big insult to the pious and the patriotic and the traditional -- Sarah Palin's long list of unfair and disrespectful treatment is one of her most attractive features. Like Oliver North, Robert Bork, and Clarence Thomas, she is known not for her ideas but as a martyr, a symbol of the culture-war crimes of the left.

To become a symbol of this stature Ms. Palin has had to do the opposite of most public figures. Where others learn to take hostility in stride, she and her fans have developed the thinnest of skins. They find offense in the most harmless remarks and diabolical calculation in the inflections of the anchorman's voice. They take insults out of context to make them seem even more insulting. They pay close attention to voices that are ordinarily ignored, relishing every blogger's sneer, every celebrity's slight, every crazy Internet rumor.

This has been Ms. Palin's assigned role ever since she stepped on the national stage last summer. Indeed, she has stuck to it so unswervingly that one suspects it was settled on even before she was picked for the VP slot, that it was imposed on her by a roomful of GOP image consultants: Ms. Palin was to be the candidate on a cross.

Evangelical Americans live under considerably more comfortable circumstances than the Islamic fanatics of Gaza. Most, according to some research, have imbibed a measure of American tolerance in their attitudes toward much behavior that their churches cast as sinful. After the multiple failures of the Bush presidency, moreover, the poison may be draining a bit out of Evangelical fervor for cultural and actual warfare. Most U.S. Evangelicals, in short, presumably would not go in for suicide bombing. But Alsan's basic equivalence between fundamentalist Islamic and Christian imaginative frames for cosmic warfare remains valid.

Wednesday, July 15, 2009

Here we go again: another pundit taking a gratuitous swipe at Francis Fukuyama. This time it's Philip Stephens:

Then, of course, there was the famous claim that the collapse of communism marked the end of history. To my mind, recent times have felt rather more like the beginning of history, but Francis Fukuyama’s career has not suffered for predicting otherwise.

Fukuyama never said "the end of history" -- the universal triumph of democratic capitalism -- was upon us. He suggested that the world is trending toward it, because competitive pressures drive countries first to open their markets and then their political systems; the "end" was at hand only in the sense that with the collapse of communism there were no viable ideological alternatives.

Indeed, Stephens' own diagnosis of China's current conundrum is pure Fukuyama. Policymakers in Beijing, he writes,

are also aware that the autocracy and corruption on which the present system rests will not withstand the pressures of economic and social change.

Only the other day Mr Hu called for a “vigorous improvement” in democratic decision-making to help fight corruption within the ruling Communist party.

Read The End of History again, Mr. Stephens. The title may "shout a single message," as you complain serious books must do these days. But the content still provides a road map for the difficult course humanity is steering.

Tuesday, July 14, 2009

All the world's a stage for Iranian prison officials. Those now producing forced confessions en masse have apparently had plenty of practice eliciting performances from ordinary prisoners. Press TV reports that seven women who face the death penalty or life imprisonment are starring in a hit in Shiraz:

Directed by Sirous Mahboudi, the production of Rebirth has opened at Abu Reyhan Hall and has been warmly welcomed by audiences. The performers appear on stage handcuffed and accompanied by prison guards, ISNA reported.

One of the prisoners, been sentenced to life for attempted armed robbery, said the excitement of live performance made her regret her earlier choices.

"I would never have involved myself in an armed heist had I known of the thrill of theater life," she mused.

Praising the cooperation of Shiraz prisons' cultural units, head of the city's theater association, Hossein Qahremani, stressed the success of the performance and offered his encouragement for similar constructive projects.

Matt Miller, a former Clinton budget official, provides rare clarity on the broad outlines of emerging U.S. healthcare reform and concludes:

Of course, just because Obama is on a path to give America the Romney health plan with McCain-style financing does not mean the Republicans will embrace it, if it seems politically more attractive to scream “socialist”. But the rest of us do not have to listen to them. Mr Obama can fairly claim to have championed a bipartisan health policy, even with few Republican votes.

Within that broader irony Miller captures a narrower one: Massachusetts healthcare reform, repudiated by the slogan-spewing former governor who signed it into law, is working:

The central mechanism through which Mr Obama seeks to extend coverage and restrain costs is via new “exchanges”, insurance clearing-houses, modelled on the plan Mr Romney enacted in Massachusetts. The idea is to let individuals access group coverage from private insurers, with subsidies for low earners.

The approach is so sensible that Ted Kennedy urged Massachusetts Democrats to support then-Governor Romney in passing it in 2006. The results have been impressive. The ranks of the uninsured have been slashed; just 2.7 per cent of residents now lack coverage, the lowest of any state – against 15 per cent nationally. Costs, which overran as the programme was brought in more quickly than planned, are now on budget.

The exchange, according to Miller - not the public plan, which he's assuming Democrats will sacrifice -- is the core of reform:

A federal version of this exchange (or federal sponsorship of state versions) would for the first time give non-elderly, non-poor Americans whose employers don’t offer coverage, or offer it at premiums they can’t afford, access to group insurance rates. It’s difficult to overstate the breakthrough this would represent. The inability of millions of Americans to access group coverage outside the employment setting is one of the most damning features of US healthcare. It means individuals with pre-existing health conditions are often uninsurable, which in turn explains why medical bills are, shamefully, a leading cause of bankruptcy. It locks budding entrepreneurs into jobs they loathe because their families need the coverage. Structuring these exchanges so health plans have incentives to compete on value is exactly the role government should play.

Miller also offers a broad perspective on cost, and an argument that ending or capping the employer tax exemption for healthcare is the logical way to pay for it:

Start with cost. It’s easy for foes to feign shock at Obamacare’s $1,000bn 10-year price tag, but a trillion dollars ain’t what it used to be. That is just over 0.5 per cent of gross domestic product over the same period, and barely 3 per cent of the roughly $35,000bn total healthcare spending during that time. If Mr Obama’s approach is otherwise sensible, the idea that America can’t afford it is preposterous...

When it comes to financing expanded coverage there’s no way to get there without revisiting the current scheme, under which employees escape taxes on employer-provided health benefits. This subsidy is so massive, at $250bn a year, and regressive – reserving its biggest bounty for those with the most generous plans – that a phalanx of health economists from both political parties recently begged Congress to trim it.

Miller's breezy assumptions that unions will cave on the employer tax exemption, and Obama and the Dems on the public plan, will be challenged by many who are deeply committed on both issues. He also does not address the crucial issue of how the emerging bill will tackle runaway healthcare inflation, which, as Peter Orzag never tires of reminding us, is the central front in the war on future deficits. But his 30,000-foot view does bring into focus the likely outlines of reform, the core issue of expanding coverage, and the absurdity of the current terms of U.S. political debate.

Monday, July 13, 2009

I was reading a pageful of Economist NY editor Matt Bishop's twitters when the rhythm triggered an aural memory. Eureka: whoever compiled (and doubtless compressed) the purported wisdom of King Solomon in the Book of Proverbs was a born twitterer:

Sunday, July 12, 2009

In several posts (1, 2, 3) noting the well-documented rise of Revolutionary Guard influence during Ahmadinejad's presidency, I have wondered how disaffected masses in Iran can effect change when the elite and paramilitary military/police forces executing the crackdown seems so fanatically devoted. What tools are at the people's (and upper-level reformists') disposal when the guns are all on the other side?

There are several possible answers to that question, and many of them are in evidence in today's Green Brief (#25) - perhaps the most dispassionate and reliable regular roundup of news inside Iran. They include the following. Indented passages below are from Green Brief 25 unless otherwise noted.

1. Economic resistance:

Vast weekly protests and the heavy presence of Basiji’s have had a negative impact on Iranian bazaars; they are finding it harder and harder to stay open. As a result, commerce is slowly coming to a standstill. Reports indicate that the opposition is in the midst of planning more strikes and protests.

Also of note on this front: the Mousavi campaign's reported cooptation of the Islamic holiday Itikaf, a 3-day period of state-sanctioned reflection and prayer, for which people are encouraged to stay home from work, as cover for a stealth strike. Some suggested that the subsequent official shut-down of government offices, justified by an intense dust storm, may have been a kind of counter-strike.

2. Some wavering in the ranks:

Reports indicate that many Basijis are quitting their jobs and are being replaced by fresh recruits, many of them under 18.

A bit of anecdotal evidence that rank-and-file conservatives are divided by the election debacle: yesterday's WSJ portrait of a fanatically devoted young Basij ended with this tale of his recently busted engagement:

For Mr. Moradani, the biggest shock during the election turmoil came in his personal life. He had recently gotten engaged to a young woman from a devout, conservative family. A week into the protests, he says, his fiancée called him with an ultimatum. If he didn't leave the Basij and stop supporting Mr. Ahmadinejad, he recalls her saying, she wouldn't marry him.

He told her that was impossible. "I suffered a real emotional blow," he says. "She said to me, 'Go beat other people's children then,' and 'I don't want to have anything to do with you,' and hung up on me."

She returned the ring he gave her, and hasn't returned his phone calls. "The opposition has even fooled my fiancée," he says.

3. Protesters' persistence

While mass protests of the sort that culminated on June 20 may be effectively quelled for now, the Green Wave is proving persistent, resilient and innovative:

Delayed reports - just emerging - confirm that protests did indeed take place around the country on July 9th. We also have authentication of mass arrests during this time. Reports of black-outs during Ahmadinejad’s speech [allegedly caused by protestors' coordinated plug-ins of as many appliances as possible] are now being confirmed by mainstream media as well (this was confirmed on twitter three days ago). ..

People in Tehran are continuing to honk their horns at the sight of Basijis - and chanting anti-government slogans while speeding away. Many people drive with their headlights on.

4. Continued resistance from high-level clerics and "old Bolsheviks" of 1979:

Many of the same scholars and journalists who have recounted the tightening grip of the Ahmadinejad/Revolutionary Guard Khamenei-backed faction have also noted that powerful elements in Iran's clerical and political elite don't like it -- and in particular, don't like Ahmadinejad. Leading dissenters include the "defeated" presidential candidates; former President and current Chairman of the Assembly of Experts and the Expediency Council Akbar Hashemi Rafsanjani; onetime Khomeini heir apparent Ayatollah Montazari; and the Association of Researchers and Teachers of Qum. That resistance is not going away:

In a letter to the Head of the Judiciary, Mahdi Karoubi – one of the candidates during the election and a key force behind the current protests – asked for the immediate release of all political prisoners as well as arrested protesters. In a letter addressed to Ayatollah Shahrodi, Karoubi claimed that, “People believed in the system, however, the system had been hijacked by a few.” He accused Tehran’s authorities of systematically eradicating opposition. He warned the government of “unimaginable consequences” if the current situation persisted.

Ayatollah Montazeri has released a Fatwa that is very supportive of protesters and their cause. In the Fatwa, Montazeri “condemned violence against protesters as un-Islamic.” He’s pleaded with the government to not play with the name of Shi’ism and Islam with their actions. He hinted that Khamenei’s leadership is standing against Islam, human rationale and National interests – and that he was clearly in the wrong. Reports of Ayatollah Ustadi - Qom's temporary Friday Prayer’s Imam - resigning his position and calling a strike could not be confirmed...

The spokesperson for Parliament's Imam’s Way Faction declared that the government’s legitimacy was “questionable” after what transpired post-election. Reports from Tehran indicate that many members within the Faction are thinking of not partaking in the “vote of confidence” that will be held in Parliament soon (the President selects a cabinet, and then a vote of confidence takes place). The spokesperson added that, “When a Cabinet Minister refuses to answer to the public, then it shouldn’t expect to get a vote of confidence”....

A number of prominent citizens in Tabriz have written a letter to Khamenei declaring that, “people were not satisfied with the election and that they will continue to voice their opposition to Ahmadinejad’s government.”

One would imagine that persistence on the part of rank-and-file Greens would be the life-blood sustaining those persisting in the upper-level power struggle. The statements released by powerful groups and individuals questioning the legitimacy of the elections are always made in the name of the people's right to a voice and the legitimacy of their protests.

The people's persistence may continue to be fueled, as in 1978-79, by that peculiar Shiite passion for and response to martyrdom, most obvious so far in the iconization of Neda, the young woman shot to death on the street after stepping out of a car into the midst of the protest of June 20. Today, twitterers are reporting a new martyr:

Sohrab, a high school senior, dies in Evin few days AFTER his mom put up bail 4 his release. #iranelection

Saturday, July 11, 2009

In Ghana as in Cairo, Obama used his biography to create standing to point out inconvenient truths to the people of the region he was visiting. He alluded to his grandfather's humiliation as a servant of British masters as prelude to saying 'don't blame colonialism for current woes.' He used his father's thwarted career as a public servant as a springboard for a focus on corruption:

Countries like Kenya had a per capita economy larger than South Korea's when I was born. They have badly been outpaced....

In my father's life, it was partly tribalism and patronage and nepotism in an independent Kenya that for a long stretch derailed his career, and we know that this kind of corruption is still a daily fact of life for far too many.

With regard to governmental corruption, Obama is picking up on a focal point of Bush policy in Africa - rewarding good governance. But --emboldened by biography perhaps -- he spoke more directly about how that corruption plays out than did Bush or Clinton:

First, we must support strong and sustainable democratic governments....

This is about more than just holding elections. It's also about what happens between elections. Repression can take many forms, and too many nations, even those that have elections, are plagued by problems that condemn their people to poverty. No country is going to create wealth if its leaders exploit the economy to enrich themselves ... or if police -- if police can be bought off by drug traffickers. No business wants to invest in a place where the government skims 20 percent off the top ... or the head of the port authority is corrupt. No person wants to live in a society where the rule of law gives way to the rule of brutality and bribery. That is not democracy, that is tyranny, even if occasionally you sprinkle an election in there. And now is the time for that style of governance to end.

He ended as he often does with a vision of a future world in which fundamental problems of today have been effectively confronted, and at the close delivered his signature "yes we can." A few moments early, however, speaking directly to the young people who, he pointed out, make up half the population in much of Africa, his message was more clearly "yes you can" - your future is in your own hands:

And here is what you must know: The world will be what you make of it. You have the power to hold your leaders accountable, and to build institutions that serve the people. You can serve in your communities and harness your energy and education to create new wealth and build new connections to the world. You can conquer disease and end conflicts and make change from the bottom up. You can do that. Yes you can ... because in this moment, history is on the move.

But these things can only be done if all of you take responsibility for your future. And it won't be easy. It will take time and effort. There will be suffering and setbacks. But I can promise you this: America will be with you every step of the way -- as a partner, as a friend. Opportunity won't come from any other place, though. It must come from the decisions that all of you make, the things that you do, the hope that you hold in your heart.

It's amazing in a way, that audacity to speak as the world's parent. The arrogance is softened by aiming the exhortation at the young. By making the young his vanguard, and by mixing in allusion to American flaws and errors, Obama carves out for himself a huge writ of moral authority.

The Wall Street Journal's Farnaz Fassihi has given us an in-depth portrait of a fanatically devoted 24 year-old "mid-ranking" Basij, Mehdi Moradani, who during the massive street demonstrations in Iran mobilized a 12-man Basij motorcycle posse that spent the days beating and arresting demonstrators.

"I was defending my country and our revolution and Islam. Everything was at risk," Mardini explains. And, "I will give my life in a heartbeat if the regime asks me."

As a representative Basij, Moradani illustrates the formidable barriers to regime change or reform in Iran. The primary enforcers are not disaffected Soviet-style conscripts, but rather true believers indoctrinated from early childhood.

Moradani was inducted at age 9 by his Revolutionary Guard father into the Basij youth club, "a mix between the Boy Scouts and Bible School," where children were primed "to defend Islam, even at the expense of death, or martyrdom." At age 14, he was mobilized to beat up student demonstrators in the 1999 uprisings. The walls of his shop are adorned with framed posters of Khamenei, Ahmadinejad, and Hezbollah leader Narsrallah - "My heroes." His cell ring is a famous religious song about a Shiite saint. There are somewhere between 1 and 4 million Basij, similarly trained.

Perhaps the most disturbing part of Fassihi's portrait is its revelation that Moradani is not fanatic enough to make the Revolutionary Guard, the elite 125,000-man military corps whose top commander defines its primary mission as " guarding the revolution and its achievements against internal threats." Ahmadinejad, a Guard veteran, has packed the government bureaucracy, governorships, media and other organs of power with fellow veterans; the Guard also controls large swaths of Iran's economy, as well as the Basij and other paramilitary groups.

For Moradani, Guard membership remains an aspiration:

He has taken the Guard's rigorous entrance exam twice, passing the ideology and the written portions both times. But he failed the final hurdle: an intense interview that lasts six to eight hours. Applicants must discuss why they are loyal to the regime and the Supreme Leader. He intends to try again.

And yet, on the other side of the coin, not every Iranian raised under a conservative ethos like Mr. Moradani has responded as he has. Having cross-sectioned the Basij with this portrait, Fassihi ends by cross-sectioning the divided society:

For Mr. Moradani, the biggest shock during the election turmoil came in his personal life. He had recently gotten engaged to a young woman from a devout, conservative family. A week into the protests, he says, his fiancée called him with an ultimatum. If he didn't leave the Basij and stop supporting Mr. Ahmadinejad, he recalls her saying, she wouldn't marry him.

He told her that was impossible. "I suffered a real emotional blow," he says. "She said to me, 'Go beat other people's children then,' and 'I don't want to have anything to do with you,' and hung up on me."

She returned the ring he gave her, and hasn't returned his phone calls. "The opposition has even fooled my fiancée," he says.

Thursday, July 09, 2009

The Iranian government, working night and day to blame the mass election protests on the reliable old bogey of Western manipulation, found an echo in the Chinese government's blaming of the Uighur riots on a prominent Uighur in exile, Rebiya Kadeer, head of a group called the World Uighur Congress.

While the Chinese charges against Ms. Kadeer are probably trumped up, they are relentlessly focused on her and the Congress -- with no suggestion of Western government support. But you'd never know that glancing at the story on Press TV, the Iranian government organ.

"In China, overseas forces blamed for Xinjiang protest" screams the headline. The phrasing is echoed in the lede, then followed by a non sequitur:

With China's violence-stricken northwestern region of Xinjiang flooded with riot police, leaders of the country's ruling Communist Party blame overseas forces for the violence.

Li Zhi, head of the Communist Party in the center of the violence, Urumqi, said many people suspected of orchestrating the riots had been arrested, adding that some were students.

“To those who have committed crimes with cruel means, we will execute them,” Li said at a press conference. “The small groups of the violent people have already been caught by the police. The situation is now under control.

You'd almost think the people orchestrating the riots were "overseas forces," wouldn't you -- and students to boot?

More than midway through the story comes the only substance to which the headline pertains:

Chinese government officials accuse US-exiled Uighur activist Rebiya Kadeer and her followers of being behind the violence.

Here, btw, is the tenor Xinhua's portrayal of the evidence that the World Uighar Congress instigated the riots. While it reads like an indictment of the Congress, again, there is no intimation of outside government involvement.

BEIJING, July 8 (Xinhua) -- The separatist World Uyghur Congress led by Rebiya Kadeer was behind the deadly July 5 Urumqi riot, in which at least 156 people died and more than 1000 were injured, sources with the government said.

Evidence showed the riot was organized. It was instigated and masterminded by the World Uyghur Congress led by Kadeer, the sources said.

The Congress used the June 26 factory brawl between Uygur and Han ethnic workers in Guangdong Province, in which two Uygurs died, to create chaos.

On July 1, the Congress held a special meeting, plotting to instigate unrest by sending messages via the Internet, telephones and mobile phones.

On July 4, some people inside the country began to send out a flood of online posts encouraging people to go to the Renmin Square in Urumqi, capital of the Xinjiang Uygur Autonomous Region, to protest on July 5 to support separatists abroad....

The Congress, an organization alleging to represent the ultimate interests of East Turkestan people, is wholly dedicated to masterminding secessionist activities in the name of human rights and democracy, the government said.

Wednesday, July 08, 2009

1. This evening, after various permutations I won't bore you with, I found myself at the kitchen table in front of a bowl cherries and a propped-up front section of today's New York Times. In my hand was my Blackberry. And therein was I reading...a story from tomorrow's Times.

2. Several weeks ago, in a Times Magazine story, I came across a reference to a chart I've seen before, showing variations by U.S. region in the average cost of treating the same disease. I thought, where's the link? Then I thought, oh, yeah -- this is the dead version. Not "the dead tree version" -- no ecological metaphor. Just a text that had no live windows to other sources.

On the other side of the coin, I worry that my capacity to read books is dimming. Maybe it's late-onset ADD, or simply a more permissible version of staring at the tube all evening, but I'm voting with my eyes, spending evenings jumping off blogs (and where Iran's concerned, twitters) into long and short articles and government documents.

Then too, my comfort reading on a Blackberry, and others' with a Kindle, makes me wonder whether books as we know them (usually, blocks of text ranging from say 50,000--500,000 words) will dissolve into a less differentiated documentland. As it is, you can already access almost anything that's past copyright from Google. This spring/summer, I've read Gatsby and most of The Scarlet Letter on my Blackberry.

All this leaves aside, for the moment, the thorny question of how authors and journalists can resume getting paid for their valuable work. I assume that commerce will eventually find a way. Meanwhile a paperless world, while arriving more slowly than some visionaries may have forecast, is I think arriving.

Which one works best? “No therapy has been shown superior to another,” an analysis by the RAND Corporation found. Which treatments are growing fastest? "Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data." Proton radiation is newer, but treatment centers, which require "a proton accelerator that can be as big as a football field," are springing up left and right.

Why do the most expensive treatments always gain traction, whether or not there's any evidence that they're effective, or more effective than cheaper treatments? Insurers -- all insurers, including Medicare -- pay per procedure. At the center of the skewed incentive system, as Gawande showed, are doctors -- who are not only paid by the procedure, but in too many cases own all or part of the treatment facilities such as medical imaging centers.

OMB Director Peter Orzag, in his drive to shape health care reform, has tried on a couple of mantras since taking office. The first was "healthcare reform is entitlement reform" -- because problems with the social security trust fund are miniscule compared with the problem of runaway health care costs. Another was "the Mayos, not the McAllens" -- framing Gawande's contrast of a county where the doctors have "gone entrepreneurial" with the Mayo Clinic, where doctors are on salary. And when ticking off the administration's proposed reforms, Orzag generally tucks in "changes in provider incentives."

The nub of incentive reform is pretty simple: put doctors on salary. Good salaries. High salaries. Sweeten the pill with tort reform, reducing the defensive medicine imperative. But remove the incentive for prescribing the most expensive care.

Tuesday, July 07, 2009

Dear readers: please note that yesterday's post noting the chilling assertion by the head of Iran's Revolutionary Guards, Mohammad Ali Jafari , that "the IRGC must play a deciding role in the preservation and continuation of the revolution" has been updated with context from a prophetic Fall '08 article by Ali Alfoneh tracking the IRGC's rise to power under Ahmadinejad after a two-decade struggle to reign it in. Alfoneh's article includes this from a Sept. 2007 speech by Jafari:

The mission of the Guards is guarding the revolution and its achievements against internal threats … The current strategy, which has been clarified by the leadership of the revolution, differs from the strategies of the [war] years. The main mission of the Guards today is countering internal threats.